Failure to Revise Care Plan After Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan following an incident of resident-to-resident physical abuse. A facility-reported incident investigation documents that one resident hit another resident on the arm in the hallway while they were talking and arguing, and a third resident witnessed the event. The resident who struck the other has medical diagnoses including fibromyalgia, dementia without behavioral disturbances, and psychosis. Their MDS shows severe cognitive impairment, physical/verbal behavioral symptoms occurring one to three times per week, wheelchair use for mobility, and a need for substantial to maximum assistance with all ADLs. Despite this incident of physical abuse, the resident’s care plan, last reviewed on 1/27/26, did not include any problems or interventions addressing the abuse or the hitting of the other resident. There was no documentation on the care plan related to the incident that occurred on 12/6/25. During interview and care plan review, the RN ADON confirmed that there was no information about the incident on the care plan and acknowledged that issues arising from incidents are to be addressed on the care plan as soon as possible. The Administrator also stated awareness that the care plan had not been revised until 2/4/26, although facility policy requires revising care plans as soon as possible after an event.
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